Endocrine aspects of postnatal mental disorders

The pathophysiology of estrogen in perinatal depression: conceptual update

PURPOSE

Estrogen levels fall sharply after parturition and have long been considered an etiologic contributor to postpartum depression (PPD); however, no differences have been reported in plasma hormone concentrations in people who develop PPD. We examine the question: What is the current view of estrogen and the neurophysiologic processes it impacts in the development and treatment of PPD?

METHODS

A literature review of the role of estrogen on candidate hormonal and epigenetic systems in the peripartum period was performed, including landmark historical studies and recent publications on estrogen-related research. The authors reviewed these papers and participated in reaching consensus on a conceptual framework of estrogen activity within the complexity of pregnancy physiology to examine its potential role for driving novel interventions.

RESULTS

Estrogen fluctuations must be conceptualized in the context of multiple dramatic and interacting changes inherent in pregnancy and after birth, including progesterone, corticosteroids, inflammation, circadian biology and psychosocial challenges. Individuals who develop PPD have increased sensitivity to epigenetic alteration at estrogen-responsive genes, and these changes are highly predictive of PPD. An effective estrogen-based treatment for PPD has yet to be found, but interventions focused on associated inflammation and circadian rhythms are promising.

CONCLUSIONS

Our understanding of the biological basis of PPD, one of the most common morbidities of the perinatal period, is expanding beyond changes in gynecologic hormone concentrations to include their impact on other systems. This growing understanding of the many processes influencing PPD will allow for the development of novel prevention and treatment strategies.

Panic disorder during pregnancy and postpartum period

Background

– Earlier studies on the influence of pregnancy and postpartum period on the course of panic disorder have been inconsistent. The present study aims to quantify panic manifestations in these periods in large sample of women.

Method

– Panic manifestations, including exacerbations and new manifestations of panic disorder, were assessed retrospectively in a sample of 128 women with panic disorder with or without agoraphobia, 93 of whom had had 195 pregnancies.

Results

– Panic manifestations were fewer during pregnancy and more frequent in the postpartum period when compared with the control period. Women who had never been pregnant had significantly more panic manifestations than women with prior pregnancies. Breastfeeding and miscarriages did not have a significant effect. Women with postpartum panic reported more psychosocial stress events during this period.

Conclusions

– Possible reasons for postpartum panic and the protective effects of pregnancy are discussed, including psychosocial or hormonal factors and other neurobiological changes. Postpartum panic coincides with a sudden drop of hormones after delivery.

Risk and childbirth in psychiatry

The relationship between childbirth and serious mental illness has been known since the time of Ancient Greece. It was first described in the psychiatric literature by Esquirol and later by his pupil Marcé in 1857. A substantial number of women become mentally ill, often for the first time, following childbirth. There are few events associated with such a measurable and predictable risk to mental health as childbirth, with its nine months warning. Despite this, there is little awareness amongst general psychiatrists of the predictable and manageable risk that faces many of their female patients should they become pregnant, nor of the risks that mentally ill mothers may pose for their children.

Review : Gonadal Steroids and Affective Illness

Gonadal steroids seem to regulate affective state in some people (but not all), despite the absence of abnormal steroid hormone levels or dysfunction of the reproductive endocrine axis. In this article, we attempt to explain this paradox 1) by describing the molecular mechanisms by which gonadal steroids can regulate neuronal function; 2) by describing the specific regulatory impact of gonadal steroids on two systems im plicated in the pathophysiology of mood disorders; and 3) by defining the role of gonadal steroids in several mood disorders linked to periods of reproductive change. We suggest that the context in which the neuro- regulatory actions of gonadal steroids occur determines the impact of steroid signaling on the regulation of affective state. NEUROSCIENTIST 5:227-237, 1999

Perinatal maternal depression and cortisol function in pregnancy and the postpartum period: a systematic literature review

BACKGROUND

Perinatal depression has a significant impact on both mother and child. However, the influence of hormonal changes during pregnancy and the postpartum period remains unclear. This article provides a systematic review of studies examining the effects of maternal cortisol function on perinatal depression.

METHOD

A systematic search was conducted of six electronic databases for published research on the relationship between cortisol and perinatal depression. The databases included; MEDLINE complete, PsychINFO, SCOPUS, Psychology and Behavioural Sciences, Science Direct and EBSCO, for the years 1960 to May 2015. Risk of bias was assessed and data extraction verified by two investigators.

RESULTS

In total, 47 studies met criteria and studies showed considerable variation in terms of methodology including sample size, cortisol assays, cortisol substrates, sampling processes and outcome measures. Those studies identified as higher quality found that the cortisol awakening response is positively associated with momentary mood states but is blunted in cases of major maternal depression. Furthermore, results indicate that hypercortisolemia is linked to transient depressive states while hypocortisolemia is related to chronic postpartum depression.

DISCUSSION AND CONCLUSION

Future research should aim to improve the accuracy of cortisol measurement over time, obtain multiple cortisol samples in a day and utilise diagnostic measures of depression. Future studies should also consider both antenatal and postnatal depression and the differential impact of atypical versus melancholic depression on cortisol levels, as this can help to further clarify the relationship between perinatal depression and maternal cortisol function across pregnancy and the postpartum period.

A reproductive subtype of depression: conceptualizing models and moving toward etiology

The lifetime risk for major depression in women is well known to be twice the risk in men and is especially high during the reproductive years between menarche and menopause. A subset of reproductive-age women experience depressive episodes that are triggered by hormonal fluctuations. Such "reproductive depressions" involve episodes of depression that occur specifically during the premenstrual, postpartum, and perimenopausal phases in women. These reproductive subtypes of depression can be conceptualized as a specific biological response to the effects of hormonal fluctuations in the brain. The different types of reproductive depressions are associated with each other, have unique risk factors that are distinct from nonreproductive depression episodes, and respond to both hormonal and nonhormonal interventions. This review uses a PubMed search of relevant literature to discuss clinical, animal, and genetic evidence for reproductive depression as a specific subtype of major depression. Unique treatment options, such as hormonal interventions, are also discussed, and hypotheses regarding the underlying biology of reproductive depression-including interactions between the serotonergic system and estrogen, as well as specific effects on neurosteroids-are explored. This review will provide evidence supporting reproductive depression as a distinct clinical entity with specific treatment approaches and a unique biology that is separate from nonreproductive depression.

The HPA axis and perinatal depression: a hypothesis

Episodes of depression and anxiety are as common during pregnancy as postpartum. Some start in pregnancy and resolve postpartum, others are triggered by parturition and some are maintained throughout. In order to determine any biological basis it is important to delineate these different subtypes. During pregnancy, as well as the rise in plasma oestrogen and progesterone there is a very large increase in plasma corticotropin releasing hormone (CRH), and an increase in cortisol. The latter reaches levels found in Cushing's syndrome and major melancholic depression. Levels of all these hormones drop rapidly on parturition.We here suggest that the symptoms of antenatal and postnatal depression may be different, and linked in part with differences in the function of the hypothalamic pituitary adrenal (HPA) axis. There are two subtypes of major depression, melancholic and atypical, with some differences in symptom profile, and these subtypes are associated with opposite changes in the HPA axis. Antenatal depression may be more melancholic and associated with the raised cortisol of pregnancy, whereas postnatal depression may be more atypical, triggered by cortisol withdrawal and associated with reduced cortisol levels. There is evidence that after delivery some women experience mild bipolar II depression, and others experience post traumatic stress disorder. Both of these are associated with atypical depression. It may also be that some women are genetically predisposed to depression of the melancholic type and some to depression of the atypical type. These women may be more or less vulnerable to depression at the different stages of the perinatal period.

Postpartum mood disorders. A startling contrast to the joy of birth

More than half of new mothers may be affected by mood disorders after childbirth. Possible causes and recommended management depend on the type of disorder and its severity. In this article, Dr Knops discusses recognition, prevention, and management of three types of postpartum mood disorders as well as the need for support for a woman and her family at this vulnerable time.

Schizophrenia and oestrogens--is there an association?

Some early psychiatrists already believed that schizophrenic disorders were associated with a disturbed balance of sexual hormones. This belief was based on the observation of a. an "insufficient functioning of the sexual glands" with so-called "hypoestrogenism", and b. an influence of ovarian function on schizophrenic psychoses. As this review shows, there are findings from recent research which seem to confirm that estrogens may have a protective effect in schizophrenia. There are also occasional hints at a possible "hypoestrogenism" in schizophrenia. In our own epidemiological, clinical and animal studies the hypothesis of a protective effect of oestrogens was for the first time systematically examined and confirmed. Oestrogens seem to modulate the sensitivity of D2-receptors in the brain, and clinically they seem to have a neuroleptic-like effect. These findings may have important implications for the prevention and therapy of schizophrenic disorders. Furthermore, our findings indicate the need to reinvestigate the question of a disturbed balance of sexual hormones in schizophrenic disorders. Further research on the role of oestrogens in schizophrenic disorders could in our opinion contribute to understanding the still unclear, possibly aetiologically heterogeneous pathogenetic mechanism of schizophrenic psychoses.